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A nurse is reviewing the medical records for clients. Which of the following findings should the nurse identify as a risk factor for violent behavior?
- A. Schizoid personality disorder
- B. Alcohol intoxication
- C. Dysthymic disorder
- D. Long-term isolation
Correct Answer: B
Rationale: The correct answer is B: Alcohol intoxication. Alcohol intoxication can impair judgment, lower inhibitions, and increase aggression, leading to a higher risk of violent behavior. Schizoid personality disorder (A) is characterized by social detachment, not necessarily violence. Dysthymic disorder (C) involves chronic low mood but not a direct risk for violent behavior. Long-term isolation (D) may contribute to mental health issues but does not directly indicate violent behavior.
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A nurse is planning care for a client who has schizophrenia and is experiencing auditory hallucinations. Which of the following interventions should the nurse include?
- A. Encourage the client to listen to loud music
- B. Ask the client directly about the content of the hallucinations
- C. Instruct the client to ignore the voices
- D. Avoid discussing the hallucinations with the client
Correct Answer: B
Rationale: The correct answer is B: Ask the client directly about the content of the hallucinations. This intervention is important as it helps the nurse understand the nature and content of the hallucinations, allowing for better assessment and tailored intervention. By directly asking the client, the nurse can gather valuable information to provide appropriate care and support. Encouraging the client to listen to loud music (A) may exacerbate the hallucinations. Instructing the client to ignore the voices (C) may not be effective and could lead to increased distress. Avoiding discussing the hallucinations with the client (D) hinders the therapeutic communication and understanding of the client's experience.
A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect?
- A. Increased energy
- B. Restlessness
- C. Euphoric mood
- D. Depersonalization
Correct Answer: B
Rationale: The correct answer is B: Restlessness. In generalized anxiety disorder, individuals often experience restlessness due to persistent worry and fear. This can manifest as physical agitation and an inability to relax. Increased energy (A) is not typically associated with generalized anxiety disorder, as individuals may feel fatigued due to constant worrying. Euphoric mood (C) is more characteristic of conditions like bipolar disorder, not generalized anxiety disorder. Depersonalization (D) involves feeling detached from oneself and is more commonly associated with conditions like dissociative disorders, not generalized anxiety disorder.
A nurse is evaluating the medication response of a client who takes naltrexone for the treatment of alcohol use disorder. The nurse should identify that which of the following is a therapeutic effect of this medication.
- A. Blocks aldehyde dehydrogenase
- B. Prevents the anxiety of abstinence
- C. Reduces substance craving
- D. Decreases the likelihood of seizures
Correct Answer: C
Rationale: The correct answer is C: Reduces substance craving. Naltrexone is an opioid receptor antagonist that helps reduce the craving for alcohol by blocking the euphoric effects associated with alcohol consumption. This medication does not block aldehyde dehydrogenase (choice A), which is involved in alcohol metabolism. It also does not prevent the anxiety of abstinence (choice B) or decrease the likelihood of seizures (choice D). Naltrexone specifically targets reducing the desire to drink, making choice C the most appropriate therapeutic effect in this scenario.
A nurse is caring for a client who has post-traumatic stress disorder (PTSD). Which of the following interventions should the nurse include in the plan of care?
- A. Encourage the client to discuss past trauma
- B. Provide a structured routine
- C. Discourage emotional expression
- D. Limit social interactions
Correct Answer: B
Rationale: The correct answer is B: Provide a structured routine. Individuals with PTSD often benefit from a predictable routine as it provides a sense of safety and control. This intervention helps regulate emotions and reduces anxiety by creating a stable environment. Encouraging the client to discuss past trauma (A) may worsen symptoms if the client is not ready. Discouraging emotional expression (C) can be harmful as it may lead to emotional suppression. Limiting social interactions (D) may increase feelings of isolation and exacerbate symptoms. It's important to prioritize stability and structure in the plan of care for clients with PTSD.
A nurse is counseling an adult client whose parent just died. The client states, 'My son is 4, and I don’t know how he’ll react when he finds out that grandpa died.' The nurse should inform the client that the preschool-age child commonly has which of the following concepts of death?
- A. Death is not permanent and the loved one may come back to life
- B. Death is contagious and can cause other people he loves to die
- C. Death creates an interest in the physical aspects of dying
- D. Death is a part of life that eventually happens to everyone
Correct Answer: A
Rationale: The correct answer is A: Death is not permanent and the loved one may come back to life. Preschool-age children often have an understanding of death as temporary, believing that the deceased may come back to life. This is due to their cognitive development and limited understanding of the finality of death. Other choices are incorrect: B is incorrect as children do not typically view death as contagious; C is incorrect as preschoolers often lack a detailed interest in the physical aspects of dying; D is incorrect as preschoolers may not fully grasp the concept of death being a natural part of life.